The key actor a qualitative study

of patient participation in the handover

process in Europe

Maria Flink12 Gijs Hesselink3 Loes Pijnenborg4 Hub Wollersheim3

Myrra Vernooij-Dassen356 Ewa Dudzik-Urbaniak7 Carola Orrego8

Giulio Toccafondi9 Lisette Schoonhoven310 Petra J Gademan11 Julie

K Johnson12 Gunnar Oumlhleacuten1314 Helen Hansagi15 Mariann Olsson12

Paul Barach1617 on behalf of the European HANDOVER Research Collaborative

For numbered affiliations seeend of article

Correspondence toMaria Flink Department ofNeurobiology Care Sciencesand Society KarolinskaInstitutet B44 KarolinskaSjukhuset HuddingeStockholm 14186 Swedenmariaflinkkise

Accepted 25 August 2012

ABSTRACTBackground Patient safety experts have postulated thatincreasing patient participation in communications duringpatient handovers will improve the quality of patienttransitions and that this may reduce hospital readmissionsChoosing strategies that enhance patient safety throughimproved handovers requires better understanding ofpatient experiences and preferences for participationObjective The aim of this paper is to explore the patientsrsquoexperiences and perspectives related to the handoversbetween their primary care providers and the inpatienthospitalMethods A qualitative secondary analysis was performedbased on individual and focus group patient interviews with90 patients in five European countriesResults The analysis revealed three themes patientpositioning in the handover process prerequisites forpatient participation and patient preferences for thehandover process Patientsrsquo participation ranged from beingthe key actor to sharing the responsibility with healthcareprofessional(s) to being passive participants For activeparticipation patients required both personal and socialresources as well as prerequisites such as information andrespect Some patients preferred to be the key actor incharge others preferred their healthcare professionals to bethe key actors in the handoverConclusions Patientsrsquo participation is related to thehealthcare system the activity of healthcare professionalsrsquoand patientsrsquo capacity for participation Patients prefer ahandover process where the responsibility is clear andunambiguous Healthcare organisations need a clear andwell-considered system of responsibility for handoverprocesses that takes into account the individual patientrsquosneed of clarity and support in relation to hishers ownrecourses

INTRODUCTION

Each transition of care including the hand-over between the inpatient hospital and thepatientrsquos home and primary care setting is a

potential threat to patient safety1 Severalstudies have found that a suboptimal patienthandover at hospital admission or dischargemay lead to adverse events with this contrib-uting to suboptimal care rehospitalisationand even death1ndash5 Deficits in handover areoften related to inadequate communicationbetween healthcare professionals with insuf-ficient or unclear information exchangedbetween the hospital and primary careprofessionals3

Safe and effective transitions of carebetween care settings require healthcare pro-fessionals that give clear unambiguous andunderstandable information to patients6 7

Some handover communication involves notonly the healthcare professionals transition-ing the patient from one phase of care to thenext but also the patient Improvements inhospital to primary care handovers thatactively include the patient in the exchangeof information between settings and health-care professionals have been associated withreduced rehospitalisation8 9 and faster deliv-ery of information to primary healthcareprofessionals3

While the knowledge about ways toimprove the hospital to primary care hand-over continuum is increasing there are fewstudies that have examined patient participa-tion in handovers The factors behind patientparticipation in the larger domain of health-care decision-making have been studiedPatients differ in their participation indecision-making based on demographicssuch as age10 health literacy10 11 nationalculture12 and expectations for participa-tion13 Improved knowledge about howpatients experience their participation in

OPEN ACCESS

BMJ Qual Saf 201201ndash8 doi101136bmjqs-2012-001171 1

Original research

BMJ Quality amp Safety Online First published on 30 October 2012 as 101136bmjqs-2012-001171

Copyright Article author (or their employer) 2012 Produced by BMJ Publishing Group Ltd under licence

groupbmjcom on October 31 2012 - Published by qualitysafetybmjcomDownloaded from

handover processes between community and hospitalcare may help in finding optimal ways of empoweringpatients that will improve the quality and safety of hand-overs This study aims to explore the experiences andperspectives of patients with chronic diseases in regardsto their participation in handover communicationbetween primary and secondary healthcare in fiveEuropean countries

METHODS

Study design and settingsThis study is a secondary analysis of data from a cross-national qualitative study of patient perspectives ontheir handovers conducted at nine hospitals and theirfeeder primary healthcare systems in the NetherlandsSpain Poland Italy and Sweden The settings werechosen to include different regional healthcare systemsand hospitals of different sizes The study was conductedas part of the European HANDOVER Project thatresearched handovers between primary and secondarycare and examined the perspectives of a wide group ofstakeholders in the transition of care between theinpatient hospital and the primary care and communitysetting (FP7-HEALTH-F2ndash2008-223409)14

Primary study populationPatients in the HANDOVER Project encompassed adultswith a chronic disease (diabetes mellitus chronicobstructive pulmonary disease (COPD) heart failure

asthma andor poly-pharmacy) who were discharged tohome directly from an inpatient hospital admissionAdditional country-specific inclusion criteria are shownin table 1 The general inclusion criteria were chosen tostudy patient handovers in both primary and secondarycare settings Patients were expected to have experiencedseveral handovers The population was chosen becausehandovers are critical for chronic and high-risk patientswho require more frequent and complex transitions6

and improving handovers for this group was thought tohave a sizable impact on their quality of care Thecountry-specific criteria were used to recruit patients whohad experienced handovers in different specialities andclinical settings Purposive sampling was used to selectpatients with the chosen diagnoses ages and gender15

Data collectionIndividual interviews were conducted with patients intheir native language in 2009 and were done in personusually at the patientsrsquo home or at the hospital 3 to4 weeks after discharge sometimes with a familymember present In all countries two members of thelocal research team conducted the interviews All inter-viewers had experience with healthcare either asresearchers or as healthcare professionals and wereexperienced interviewers or had attended a series ofworkshops on qualitative interviewing to ensure standar-dised methodsFocus group interviews were performed in the

patientsrsquo native language Focus groups were led by a

Table 1 Study sample

Country

Individual

interviews

(n=53)

Focus group

interviews

(n=37)

Country specific inclusion

criteria General inclusion criteria

The

Netherlands

n=8 n=7 Patients admitted to internal

medicine pulmonary diseases

cardiology or (vascular) surgical

wards

gt18 years

Diagnosed with either diabetes

mellitus chronic obstructive

pulmonary disease (COPD)

heart failure asthma orand

poly-pharmacy (gt6 drugs)

Discharged to home or nursing

home (under responsibility of

primarycommunity care)

Spain n=8 n=3 Patients belonging to cultural

minority groups with

limited health literacy (capacity to

read write and understand

healthcare information)

Poland n=23 n=10 Patients ge60 of age

Italy n=5 n=9 Patients admitted to emergency

ward

Sweden n=9 n=8 Patients admitted to emergency

ward via emergency room If

living at a nursing home only

within a geographically specified

area

Number of participants by country and inclusion criteria

2 BMJ Qual Saf 201201ndash8 doi101136bmjqs-2012-001171

Original research

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trained moderator and had one or two observers whomade field notes and added question prompts All inter-views were audio-taped and transcribed verbatim in thelocal language according to a jointly decided standar-dised formatBoth individual and focus groups interviews used a

semistructured interview guide developed in English bythe HANDOVER Project researchers and translated intothe local language of the research groups16 The inter-view guide covered these areas of interest Experience with recent handovers (appreciative

problematic situations and consequences) Perceptions about handovers in general (ie experi-

ences attitudes methods tools barriers facilitators) Perceptions about providerpatient tasks roles and

responsibilities Suggestions for improving patient handoversThe guide was piloted in each country and when

necessary adjusted for local conditions and needs (avail-able upon request)A quality assurance protocol17 based on BMJ criteria18

and on criteria presented by Tong et al15 was developed(by MVD and JKJ) and used to ensure trustworthinessthroughout the data collection and data analysesRequirements for informed consent and other ethicaland legal requirements for research using patient infor-mation were fulfilled at all study sites

Sample for secondary analysisFor the secondary analysis data were extracted frompatient interviews in the five countries participating inthe HANDOVER Project The sample consisted of 90patients 53 individually interviewed (55 of the overallsample of patients interviewed individually for the ori-ginal studies conducted as part of the HANDOVERProject) and 37 interviewed in focus groups (100 ofthe overall sample of patients interviewed in groups)

The distribution across countries is shown in table 1Where the gender distribution of the primary samplewas reported it included approximately equal numbersof male and female patients

Data analysisThe analysis consisted of two main parts analysis ofinterviews at the national level and a secondary ana-lysis19 of the cross-national data (see figure 1)

Analysis at national levelTwo interviews from each country were translated intoEnglish and coded inductively using a modifiedgrounded theory approach of Corbin and Strauss20 Aqualitative data analysis software (Atlasti) was used tofacilitate storing coding and indexing of the data21 Theresearchers created a codebook based on codes gener-ated in each country The codebook consisted of thecode and an operational definition both of which wereagreed upon during regularly scheduled conference-calls and face to face meetings and was used for analysisof both individual and focus group interviews Tworesearchers in each country analysed their countryrsquos datain parallel with the data collection and continued tocollect data until conceptual saturation was reached andno new codes or categories were generated20 Localreports were written in English by one or two of theresearchers in each country and used for compiled ana-lyses for the European HANDOVER Project studiesThese studies focused on barriers and facilitators toeffective handovers patient roles and responsibilitiesand patient-centredness and participation culture16 22 23

Secondary analysisThe local reports including quotes from the individualinterviews and focus groups were used for the

Figure 1 Proceduremdashfrom data collection to the current secondary analysis

BMJ Qual Saf 201201ndash8 doi101136bmjqs-2012-001171 3

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secondary analysis which focused on patientsrsquo perspec-tive on their own participation in handovers Thus thissecondary analysis seeks to answer a new research ques-tion19 using data that was already collectedLocal reports were analysed using a qualitative induct-

ive content analysis as described by Hsieh andShannon24 Two authors (MF MO) coded the texts inopen coding and three authors (MF MO GH) sortedthe codes into categories and themes Validity checkinginvolved all authors of the local reports who reviewedthe findings to ensure they were consistent with the ori-ginal interview data

RESULTS

The data analysis resulted in eight categories fromwhich three themes were developed (1) patient position-ing in the handover process (2) prerequisites for patient partici-pation and (3) patient preferences for the handover process(see table 2)

Patient positioning in the handover processThree types of patient experiences form the categoriesunder this theme (a) patients as the key actors in thehandover process (b) patients sharing the responsibilityfor the handover with healthcare professionals and (c)healthcare professionals functioning as the key actors inthe handover process

Patients as the key actors in the handover processPatients assumed the responsibility for the handovercommunication including establishing contact with thenext care unit as well as the responsibility for collectingstoring and handing over essential information for man-aging their care such as medication lists or dischargenotes For example when a healthcare professional inthe hospital setting in Italy wrote the discharge note totransition the patient to the primary care settingmdashthisdischarge note was given to the patient for delivery tothe general practitioner The key actor positioning wasmost explicitly stated by the geriatric patients in Polandwho noted they needed to take responsibility in organis-ing the handovers as well as being couriersPatients who functioned as key actors perceived their

active involvement was required for an effective hand-over and to ensure continuity of care These patientshad either learned from past experiences that little orno information was transferred unless they did it them-selves or perceived that healthcare professionalsexpected them to assume the initiative and be activeduring their handovers

Patient Poland ldquoWell we all know by now that it[general practitioner ndash hospital communication] doesnrsquotexist You want a referralmdashthen you get it Then Iarrange my admissionmdashneither my general practitionernor hospital physician care helliprdquo

Being the key actor could cause some patients toblame themselves for not fulfilling the task of facilitatingthe handover when information was lacking betweencare settings

Patient Italy ldquoIt was our fault We forgot to contact thegeneral practitioner during the hospitalisationrdquo

Patients sharing the responsibility for the handoverwith healthcare professionalsExamples of patients sharing responsibility for the hand-over with healthcare professionals were found in Swedenfor patients who were admitted for acute conditionsThese patients participated in sharing essential or spe-cific information for their care transition which comple-mented the handover communication conducted by thehealthcare professional For example during hospitaladmissions the patients informed healthcare profes-sionals about their medications and previous care epi-sodes and at discharge they informed the healthcareprofessionals about the name or address of their generalpractitioner to ensure that the correct primary care pro-fessional received the handover information Healthcareprofessionals actively encouraged patients to share theresponsibility for communication such as ensuring thatproper information was shared between the hospital and

Table 2 Categories and themes

Categories Themes

1 Patients as the key actors

in the handover process

2 Patients sharing the

responsibility for the

handover with healthcare

professionals

3 Healthcare professionals

functioning as the key

actors in the handover

process

A Patient positioning in

the handover process

4 Actions required for patients

to be key actors

5 Resources and discipline

required to be the key actor

6 Facilitators for and barriers

to patient participation

B Prerequisites for

patient participation

7 Patient preferences for

being the key actors

8 Patient preferences

regarding healthcare

professionals serving as the

key actors

C Patient preferences for

the handover process

4 BMJ Qual Saf 201201ndash8 doi101136bmjqs-2012-001171

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communityprimary care settings and asked of thepatients to assume responsibility for their own health

Patient Sweden ldquoThey used to say please call theadvanced home care services just for safety reasons andtell them yoursquore back homerdquo

Healthcare professionals functioning as the key actorsin the handover processSome patients viewed the healthcare professionals as thekey actors in the handover process These patientsassumed that handovers are performed by healthcareprofessionals focusing on verbal andor written commu-nication electronic mail or medical records data sharedbetween the care settings This more passive positioningin the handover was found among the Dutch patientsSome hospitals in the Netherlands had a dedicatedlsquotransfer nursersquo to manage handovers to the primarycare setting after discharge

Patient Netherlands ldquoYes I indeed think that if the hos-pital takes responsibility to discharge patients becausethey think they can manage outside the hospital theyalso have to take that responsibility and arrange an alter-native solution if itrsquos not possiblerdquo

Prerequisites for patient participationThis theme had three categories (a) actions requiredfor patients to be key actors (b) resources and disciplinerequired to be the key actor and (c) facilitators for andbarriers to patient participation

Actions required for patients to be key actorsTo be able to function as key actors patients had toassume the responsibility that is take initiatives and askthe healthcare professionals questions to get the neededinformation

Patient Spain ldquoIn order to have more information it isimportant to ask hellip and sometimes you ask a questionand they answer ldquoWell I donrsquot knowWait please I willask somebodyrdquo hellip and they donrsquot tell you anythingrdquo

In addition patients had to be explicit and sometimesbe assertive in their communication with the healthcareprofessionals to help the handover move forward

Resources and discipline required to be the key actorPatients acknowledged the importance and the potentialof having own resources and noted they investigatedtheir social network to find the best healthcare profes-sional available Patients also used their available familyand contact resources Family members sometimesreplaced the patient in taking responsibility for

conveying handover information and acting as medicalsecretaries or information conduitsPatients with limited personal resources or with low

health literacy had difficulties understanding thereceived information and sharing the information withthe healthcare professionals This limited their participa-tion in the handover communication

Patient Spain ldquoWhat can I say The main thing was thatI could not speak in Spanish so I canrsquot express manythings so that is the problemrdquo

In order to function as the key actors in the handovergeriatric patients in Poland had to be disciplined inorganising and transferring medical documents as theywere the main repository of patient documentation Inthis model lack of discipline and willingness to systemat-ically collect relevant documents were barriers to effect-ive handovers

Patient Poland ldquoIf the patient does not want and would notcomply the best doctor would not (be able to) help himrdquo

Facilitators for and barriers to patient participationPatients reported on several communication facilitators andbarriers related to their participation Patients perceived apositive climate for communication based on mutualrespect in an open atmosphere and on a personal levelbetween them and the healthcare professionals as an enab-ling factor for participation in the handover Accordingly anegative climate for communication involved healthcareprofessionals neglecting patientsrsquo individual needs or beingtoo busy to communicate with patientsLack of information was the main barrier to participa-

tion during the handover process Patients perceived a gapbetween the information they received and the informa-tion they actually needed for continuous care Informationgaps often concerned medication information whenpatients were discharged with unclear or insufficient infor-mation on how best to handle their medications orwithout a new and updated medication list they could notparticipate actively in follow-up Finally the patientsexpressed the need for a dedicated discharge encounterin which they would be given all the information neededthat could help them improve their postdischarge care

Patient Italy ldquoI go back home with a bag of drugs and trustme that this was a mess I could not sort out hellip They didnrsquottell us that there could be a risk of depression I had amedical discharge report they have been really good forGodrsquos sake but they did not explain to us enoughrdquo

Patient preferences for the handover processThere are two categories under this theme (a) patientpreferences for being the key actors and (b) patient

BMJ Qual Saf 201201ndash8 doi101136bmjqs-2012-001171 5

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preferences regarding healthcare professionals servingas the key actors

Patient preferences for being the key actorsThe preference for being key actors in the handoverprocess was expressed by Swedish patients undergoingacute admissions by geriatric patients in Poland and bypatients in the Netherlands These patients stressed theimportance of patients in contributing to an effectivehandover For example Swedish patients noted thatwhen they assumed responsibility for the handover com-munication worked better It also empowered them andgave them a sense of control over the handover processPatients also found the opportunity to look up andascertain the accuracy of the information being trans-ferred an advantage

Focus group Netherlands

ldquoPatient A You receive the letter and you deliver it to thedoctor and then the general practitioner will visit to seehow you are doing so this is very satisfying for me yes

Interviewer So you are satisfied with this that the infor-mation is routed via you

Patient B I find it an advantage when it is routed via thepatient

Patient A Yes and itrsquos also true that you are certain theinformation is coming acrossrdquo

Patient preferences regarding healthcare professionalsserving as the key actorsPatients who indicated a preference for healthcare pro-fessionals to be the key actors in the handover perceivedhandovers more effective when healthcare professionalswere actively involved These patients felt that profes-sionals should be fully responsible for the handover andreported feeling frustrated when urged to take responsi-bility for the handover and wanted a passive role in theircare Some patients mentioned a transfer nurse as thepreferred key actor for handovers

Relative Sweden ldquoThey should have somebody whoalways gets in touch with the nursing home Someoneresponsible that can take care of all contactsrdquo

One subgroup patients with low health literacy didnot express any preferences regarding participating ornot participating in the handover process

DISCUSSION

Three themes of importance for patient participationwere revealed in the study patient positioning in the

handover process prerequisites for patient participationand patient preferences for the handover processes Thisstudy does not make comparisons across countriesInstead the aim was to study patient participation in hand-over processes with different characteristics in variouscare settings to explore patientsrsquo perspectives moreindepth The findings demonstrate that patientsrsquo position-ing ranged from being the key actor sharing the responsi-bility with healthcare professionals to being passivePatientsrsquo positioning seems to respond to the hand-

over system in an elastic relation and are modulated bytheir perceptions of the healthcare professionals actionsIn systems with less active engagement of healthcare pro-fessionals patients assumed a more active position whilein systems with active engagement particularly by dedi-cated professionals like transfer nurses patients assumeda more passive position Other studies have found thatpatient participation differs depending on the settingspatient and physician attributes10 25 26 and the experi-ences of patient participation in the handover processesmirror these findings Due to the fact that our study wasa secondary analysis of the data we cannot be sure towhich degree the positioning continuum was a result ofthe patient characteristic or reflects the characteristics ofthe participating nationsrsquo healthcare systemsThe passive role of some patients in the handover may

be a consequence of these individuals lacking informationor instructions from healthcare professionals that wouldallow them to actively participate or a lack of personalresources capabilities or discipline To be able to partici-pate actively patients required certain resources and prere-quisites (eg social network health literacy and clearinformationinstructions) as well as being treated withrespect Two recent reviews on patient participation foundpositive outcomes of patient participation include betterinteraction between patients and healthcare professionalsand enhanced patient safety10 27 The findings of this studythus raise the question whether the quality of handovers isreduced when patients are passive participants becausethey may lack the prerequisites for active participationMany patients did not state a preference for shared

responsibility as one might have expected but preferredthat either the healthcare professionals or the patientfunctioned as the key actor We have not found anyearlier studies on patient preferences regarding assum-ing handover responsibility Comparing our findings tostudies on patient participation in decision-making11 28

reveals that patients choose to be passive participantswhen their involvement may have a negative affect onthe outcome of the decision when decisions arecomplex and when patients were severely ill10 11

Patients with cancer preferred a shared or an activerole28 Patientsrsquo preference for healthcare professionalsto be the key actors in our study may be explained by

6 BMJ Qual Saf 201201ndash8 doi101136bmjqs-2012-001171

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their chronic disease status and the requirement forsharing complex medical information as well as in thepatientsrsquo statements that a handover process with clearresponsibility was most effective Because patients in theprimary interviews were not explicitly asked about theirinterest in shared responsibility we cannot exclude thatsome patientsrsquo desire shared responsibility However ourfindings suggest that patients in our analysis appeared toprefer clarity about who is responsible for the handoverirrespective of whether the patient or the health profes-sionals function as the key actorThe study has several limitations First the initial trans-

lations of the interviews were conducted in the respect-ive countries by the researchers themselves and not byprofessional translators and the secondary analysis wasperformed on the English text by Swedish and Dutchresearchers raising concerns about the potential for lin-guistic misinterpretation This risk was reduced byhaving both the primary researchers and the individualswho conducted the secondary analysis actively involvedin discussions about the study aim and methods byhaving all steps in data collection and analysis monitoredusing a quality assurance programme17 and by ensuringthat the authors of the local reports have read and con-firmed the accuracy of data from the secondary analysisAlso the secondary analysis was not performed directlyon the original data but on data already selected forlocal reports by researchers and it was not possible toconduct a validity check with the original patients inter-viewed Third patient-specific information on age andthe distribution of the chronic conditions is not knownfor the sample for secondary analysis The primary studypopulation in the HANDOVER-study included a repre-sentative distribution by age gender and diagnoses16 22 23

Finally the population was restricted to adult patientswith chronic conditions which may limit the ability totransfer the findings across all handoversThe methodological limitations with secondary analysis

have been well described by Thorne19 A key issue lies inthe distance between the original data sourcemdashthepatientsmdashand the secondary question about patient partici-pation This question was however a natural extension fromthe primary research questions of the HANDOVER-study

CONCLUSIONS

This study despite its limitations increases our knowl-edge of the preferences of patients for participating inthe handover between the inpatient and the primarycare setting Patient participation in handovers betweenprimary and hospital care is related to the healthcaresystem the activity of healthcare professionals and thepatients themselves The ability to participate and take

an active positioning requires patientsrsquo personal andsocial resources prerequisites such as personal and clearinformation and respectful treatment by healthcare pro-fessionals Patients prefer a handover process where theresponsibility for the handover communication is clearand unambiguous that is a system that ensures them intransparent manner there is continuity of their careThis is an important finding for efforts to improvepatient handovers to create and sustain greater reliabil-ity transparency and consistencyFuture improvements of the patient handover will

require the healthcare organisations to develop a clearand well-considered system of assigning responsibility forthis process Regardless of the system chosen the indi-vidual patientrsquos need of clarity and a level of supportthat is tailored to hisher own resources and ability toparticipate in the handover must be taken into accountFuture development and research is needed to find outhow a shared responsibility could look like in practiceand be unambiguous for the patients Such knowledgecan help enhance safe patient transitions between thehospital and the patientrsquos home

Author affiliations1Department of Neurobiology Care Sciences and Society KarolinskaInstitutet Stockholm Sweden2Department of Social Work Karolinska University Hospital StockholmSweden3Scientific Institute for Quality of Healthcare (IQ healthcare) RadboudUniversity Nijmegen Medical Centre Nijmegen The Netherlands4Department on Quality and Safety St Antonius Hospital and Department onQuality and Safety St Antonius Hospital Nieuwegein The Netherlands5Department of Primary Care Radboud University Nijmegen Medical CentreNijmegen The Netherlands6Kalorama Foundation Radboud University Nijmegen Medical CentreNijmegen The Netherlands7National Center for Quality Assessment in Health Care Krakow Poland8Avedis Donabedian Research Institute (FAD) Universitat Autogravenoma deBarcelona and CIBER Epidemiology and Public Health (CIBERESP) BarcelonaSpain9Clinical Risk Management and Patient Safety Centre Tuscany RegionFlorence FI Italy10Faculty of Health Sciences University of Southampton Southampton UK11Primary Health Care Utrecht Area Utrecht The Netherlands12Centre for Clinical Governance Research University of New South WalesSydney Australia13Department of Clinical Science Intervention and Technology KarolinskaInstitutet Stockholm Sweden14Quality and Patient Safety Karolinska University Hospital StockholmSweden15Department of Clinical Neuroscience Karolinska Institutet StockholmSweden16Patient Safety Center University Medical Center Utrecht UtrechtThe Netherlands17Department of Health Studies University of Stavanger Stavanger Norway

Acknowledgements We would like to thank all participating patients forsharing their valuable experiences

Collaborators The European HANDOVER Research Collaborative consists ofVenneri F Albolino S Molisso A Toccafondi G (Azienda Sanitaria FirenzeFlorence Italy) Barach P Gademan P Goumlbel B Johnson J Kalkman CPijnenborg L (Patient Safety Center University Medical Center Utrecht

BMJ Qual Saf 201201ndash8 doi101136bmjqs-2012-001171 7

Original research

groupbmjcom on October 31 2012 - Published by qualitysafetybmjcomDownloaded from

Utrecht The Netherlands) Wollersheim H Hesselink G Schoonhoven LVernooij-Dassen M Zegers M (Scientific Institute for Quality of HealthcareRadboud University Nijmegen Medical Centre Nijmegen The Netherlands)Boshuizen E Drachsler H Kicken W van der Klink M Stoyanov S (Centre forLearning Sciences and Technologies Open University Heerlen theNetherlands) Kutryba B Dudzik-Urbaniak E Kalinowski M Kutaj-WasikowskaH (National Center for Quality Assessment in Health Care Krakow Poland)Suntildeol R Groene O Orrego C (Avedis Donabedian Institute UniversidadAutoacutenoma de Barcelona Barcelona Spain) Oumlhleacuten G Airosa F Bergenbrant SFlink M Hansagi H Olsson M (Karolinska University Hospital StockholmSweden) Lilford R Chen Y-F Novielli N Manaseki-Holland S (University ofBirmingham Birmingham UK)

Contributors Study conception and design MF LP HW MVD CO LS JKJGO HH MO and PB Acquisition of data MF GH LP HW EDU CO GT PGand MO Analysis at national level- the local reports MF GH LP EDU COGT PG and MO Secondary analysis MF GH MVD MO Drafting andorrevising the article MF GH LP HW MVD EDU CO GT LS PG JKJ GOHH MO and PB

Funding This study was supported by a grant from the European Union theFramework Programme of the European Commission (FP7-HEALTH-F2-2008-223409) The study sponsor had no role in the study design collectionanalysis and interpretation of the data or in the writing of the article anddecision to submit the article for publication

Competing interests None

Ethics approval Ethical review boards in the Netherlands Spain Poland Italyand Sweden

Provenance and peer review Not commissioned externally peer reviewed

Data sharing statement Data are available on request from the correspondingauthor

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medical patients after discharge from hospital Can Med Assoc J2004170345ndash9

2 Forster AJ Murff HJ Peterson JF et al The incidence and severityof adverse events affecting patients after discharge from thehospital Ann Intern Med 2003138161ndash7

3 Kripalani S LeFevre F Phillips CO et al Deficits in communicationand information transfer between hospital-based and primary carephysiciansmdashImplications for patient safety and continuity of careJAMA 2007297831ndash41

4 Moore C Wisnivesky J Williams S et al Medical errors related todiscontinuity of care from an inpatient to an outpatient setting J GenIntern Med 200318646ndash51

5 Tam VC Knowles SR Cornish PL et al Frequency type andclinical importance of medication history errors at admission tohospital a systematic review Can Med Assoc J 2005173510ndash15

6 Halasyamani L Kripalani S Coleman E et al Transition of care forhospitalized elderly patientsmdashDevelopment of a discharge checklistfor hospitalists J Hosp Med 20061354ndash60

7 Johnson A Sandford J Written and verbal information versus verbalinformation only for patients being discharged from acute hospitalsettings to home systematic review Health Educ Res200520423ndash9

8 Coleman EA Parry C Chalmers S et al The care transitionsinterventionmdashResults of a randomized controlled trial Arch InternMed 20061661822ndash8

9 Jack BW Chetty VK Anthony D et al A reengineered hospitaldischarge program to decrease rehospitalization A randomized trialAnn Intern Med 2009150178ndash88

10 Davis RE Jacklin R Sevdalis N et al Patient involvement in patientsafety what factors influence patient participation and engagementHealth Expect 200710259ndash67

11 Say R Murtagh M Thomson R Patientsrsquo preference for involvementin medical decision making A narrative review Patient Educ Couns200660102ndash14

12 Meeuwesen L van den Brink-Muinen A Hofstede G Candimensions of national culture predict cross-national differences inmedical communication Patient Educ Couns 20097558ndash66

13 Coulter A Jenkinson C European patientsrsquo views on theresponsiveness of health systems and healthcare providers Eur JPublic Health 200515355ndash60

14 Improving the continuity of patient care through identification andimplementation of novel patient handover processes in Europehttpwwwhandovereu (accessed 21 Oct 2011)

15 Tong A Sainsbury P Craig J Consolidated criteria for reportingqualitative research (COREQ) a 32-item checklist for interviews andfocus groups Int J Qual Health Care 200719349ndash57

16 Hansagi H Olsson M Glas S et al Report on the barriers andfacilitators to effective handovers in the social linguistic andtechnological context in which they take place UtrechtThe Netherlands Utrecht Medical Center for the European Union2010

17 Johnson J Barach P Vernooij-Dassen M A standardized approachfor conducting qualitative research across multiple countries BMJQuality and Safety 2012

18 Mays N Pope C Qualitative research in health care Assessingquality in qualitative research BMJ 200032050ndash2

19 Thorne S Ethical and representational issues in qualitativesecondary analysis Qual Health Res 19988547ndash55

20 Corbin J Strauss A Grounded theory research Procedurescanons and evaluative criteria Qual Sociol 1990133ndash21

21 ATLASti Scientific Software Development Company GmbH BerlinGermany httpwwwatlasticom (accessed 21 Mar 2011)

22 Barach P Gademan P Kalkman C et al Report on how variationsin handover processes lead to near misses and adverse outcomesand identifying standardized elements of communication UtrechtThe Netherlands Utrecht Medical Center for the European Union2010

23 Hesselink G Wollersheim H Barach P et al Report on challengesin patient care and the factors that influence change in practiceUtrecht The Netherlands Utrecht Medical Center for the EuropeanUnion 2010

24 Hsieh HF Shannon SE Three approaches to qualitative contentanalysis Qual Health Res 2005151277ndash88

25 Street RL Jr Krupat E Bell RA et al Beliefs about control in thephysician-patient relationship effect on communication in medicalencounters J Gen Intern Med 200318609ndash16

26 Street RL Jr Gordon HS Ward MM et al Patient participation inmedical encounters why some patients are more involved thanothers Med Care 200543960ndash9

27 Longtin Y Sax H Leape LL et al Patient participation currentknowledge and applicability to patient safety Mayo Clin Proc20108553ndash62

28 Tariman JD Berry DL Cochrane B et al Preferred and actualparticipation roles during health care decision making in personswith cancer a systematic review Ann Oncol 2010211145ndash51

8 BMJ Qual Saf 201201ndash8 doi101136bmjqs-2012-001171

Original research

groupbmjcom on October 31 2012 - Published by qualitysafetybmjcomDownloaded from

doi 101136bmjqs-2012-001171 published online October 30 2012BMJ Qual Saf

Maria Flink Gijs Hesselink Loes Pijnenborg et al Europeparticipation in the handover process in The key actor a qualitative study of patient

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(DOIs) and date of initial publication publication Citations to Advance online articles must include the digital object identifier citable and establish publication priority they are indexed by PubMed from initialtypeset but have not not yet appeared in the paper journal Advance online articles are Advance online articles have been peer reviewed accepted for publication edited and

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